Baylor University Medical Center Proceedings April 2017 - 232

Atrial fibrillation 50 years after acute rheumatic fever as the
first manifestation of rheumatic mitral stenosis
D. Luke Glancy, MD

Figure. Electrocardiogram in a dyspneic patient with a history of polyarthritis due to acute rheumatic fever 50 years earlier. See text for explication.

A

56-year-old woman had a history of acute rheumatic
fever with polyarthritis at age 6 years. She had been
seen intermittently as an outpatient at our hospital over
the past 6 years with systemic arterial hypertension,
obesity, adult-onset diabetes mellitus, and peptic ulcer disease.
All of her electrocardiograms over that period showed left atrial
enlargement, and many had large QRS voltage consistent with
left ventricular enlargement. She was never told of rheumatic
heart disease.
On the day of admission, she came to the emergency department with the new onset of palpitations, diaphoresis, and
dyspnea. An electrocardiogram showed atrial flutter/fibrillation
with an irregular ventricular response at 156 beats/minute,
Ashman's phenomenon, and nonspecific ST-T changes (Figure).
232

The couplet of wide QRSs with right bundle branch block
configurations just past the middle of the tracing could have
been a couplet of left ventricular premature complexes, but
was not followed by a pause and was more likely an example of
Ashman's phenomenon. The first wide QRS followed a short
R-R interval that followed a longer R-R interval. The longer
interval caused the refractory period after the last narrow QRS
to lengthen, and when the next impulse from the atria entered
the atrioventricular conduction system early, it was blocked
From the Section of Cardiology, Department of Medicine, Louisiana State
University Health Sciences Center, New Orleans, Louisiana.
Corresponding author: D. Luke Glancy, MD, 1203 West Cherry Hill Loop, Folsom,
LA 70437 (e-mail: dglanc@lsuhsc.edu).
Proc (Bayl Univ Med Cent) 2017;30(2):232-233



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